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Long Term Disability (ERISA or Private)

'The difference between litigating against Scott Elkind and having a colonoscopy is at least you get anesthesia with the colonoscopy.' -Anonymous Opposing Counsel

Many people obtain long-term disability benefit policies either through their job or they purchase it on their own. These policies provide financial benefits to people who become disabled either by accident or illness. Most people expect the companies providing this insurance to keep their promise and pay benefits if they become disabled. Unfortunately, in many circumstances, this is not the case and policyholders learn the hard way that a promise made can quickly turn into a promise broken.

Insurers are required to undertake a full and impartial claims review of all disability benefit applications. Many insurers make little or no effort to evaluate disability benefit claims. Often, they fail to obtain critical medical records or job duty information before issuing a denial. In addition, many insurers frustrate Claimants by using complicated forms, making unreasonable documentation requests, and/or requiring multiple examinations by "independent" doctors who seemingly have little interest in doing a proper exam and are centered on making findings to buttress an insurer's predetermined denial of benefits. Long delays in "review" are extremely common which become extremely frustrating to Claimants who must wait months on end without any income assistance often to receive bad news. During this process, Claimants often perceive the process as futile and will fail to seek much needed legal assistance in order to obtain benefits for their deserving claim.

If you take the time to review your disability policy, you will see that it is a complex document filled with poorly defined terms. Included in the policy language are many terms which must be satisfied so as to qualify for coverage and other terms which seek to limit coverage in many ways. Insurers will try to use various policy provisions to limit benefit payments or avoid payment altogether. For these reasons, a complete understanding of the policy terminology is essential to making a benefits claim and interpreting a policyholder's potential entitlements as limited under the same policy. In simpler terms, the policies of insurance often giveth and taketh away simultaneously.

As a practical matter, it is important to seek the advice of an attorney whenever a disability insurer begins tactics which seem burdensome, unusual, or unfair. Often, effective assistance of counsel at the outset can prevent many delays in claims processing which would otherwise occur due to a Claimant’s lack of understanding of the claims process. Insurers rely on the relative inexperience of Claimants in order to manipulate and delay the claims process. Many times, there are administrative appeals available to Claimants, which, if skillfully used, can lead to getting the claim approved. If the appeals process is not used properly, this can lead to an irreversible claims denial. Under no circumstance should a Claimant pursue an appeal without legal counsel. Although it should go without saying, a Claimant’s request for appeal without submitting documentation proving disability under the policy terms. A Claimant’s blind reliance on the insurer to "review" a denial by requesting an appeal without fully documenting the disability claim is nothing less than an opportunity to rubber stamp the original denial and force litigation.

In some cases, litigation will be necessary, even in cases, which the disability is inarguable. Just because your treating physician writes a report that states that you are disabled is no guarantee that you will receive benefits. More often than not, the insurer’s in-house physician will write a contrary finding, which will only be buttressed by the examining "independent" physician hired by the insurer. When receiving benefits is of drastic economic importance, it is amazing how many Claimants fall prey to insurers and their empty promises of benefits and false hopes of fair "appeals" within the disability benefit application process. Often Claimants learn only too late that they engaged in a game with dealer utilizing a "stacked" deck. This realization often occurs at the same time that no assistance will be available from their former employer or insurance broker originally responsible for obtaining the policy of insurance.
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